Augmentin Dosing for Otitis Media
For acute otitis media in children, use high-dose amoxicillin-clavulanate (Augmentin) at 90 mg/kg/day of the amoxicillin component with 6.4 mg/kg/day of clavulanate (14:1 ratio) divided into 2 doses daily. 1, 2
When to Use Augmentin vs. Amoxicillin Alone
Augmentin should be your first-line choice in three specific scenarios:
- Recent amoxicillin exposure: Child received amoxicillin within the previous 30 days 1, 2
- Concurrent conjunctivitis: The otitis-conjunctivitis syndrome suggests β-lactamase-producing organisms 1
- Treatment failure: Initial amoxicillin therapy failed after 48-72 hours 1, 2
Otherwise, standard high-dose amoxicillin (80-90 mg/kg/day) remains first-line for uncomplicated acute otitis media. 1, 2
Specific Dosing Details
The 14:1 formulation (90/6.4 mg/kg/day) is critical because it provides adequate coverage for resistant pathogens while causing significantly less diarrhea than older 7:1 formulations. 1
- Frequency: Divide total daily dose into 2 doses (twice daily) 1, 3
- Duration: Typically 10 days for standard treatment 4, 5
- Maximum dose: Follow manufacturer's maximum adult dosing limits
Why This Specific Formulation Matters
The high-dose 14:1 ratio formulation achieves several goals:
- Covers penicillin-resistant Streptococcus pneumoniae: Achieves middle ear fluid levels exceeding the MIC for intermediately resistant (MIC 0.12-1.0 μg/mL) and many highly resistant strains (MIC ≥2 μg/mL) 1, 6
- Covers β-lactamase producers: Effective against β-lactamase-producing Haemophilus influenzae (58-82% of strains) and Moraxella catarrhalis 1, 6
- Reduces gastrointestinal side effects: The 14:1 ratio causes substantially less diarrhea (8.7-9.6%) compared to the older 4:1 ratio formulation (26.7%) 1, 5
Efficacy Evidence
High-dose amoxicillin-clavulanate demonstrates superior bacteriologic eradication:
- 96% eradication rate for S. pneumoniae at days 4-6 of therapy 1
- 77.8-84.6% successful bacteriological response at end of therapy 4
- Clinical cure rates of 86.5-94% comparable to or better than alternatives 4, 3
Twice Daily vs. Three Times Daily Dosing
Use twice-daily dosing - it provides equivalent efficacy with better compliance and fewer side effects:
- No difference in clinical cure rates between twice and three times daily dosing (RR 1.02,95% CI 0.95-1.09) 1, 3
- Higher compliance: 82.8% with twice daily vs. 73.3% with three times daily 4
- Less diarrhea: 9.6% with twice daily vs. 26.7% with three times daily 4, 5
Common Pitfalls to Avoid
- Don't use lower-dose formulations: The standard 40/10 mg/kg/day formulation lacks adequate coverage for resistant S. pneumoniae 1
- Don't use the wrong ratio: Older 7:1 or 4:1 formulations cause significantly more diarrhea without improved efficacy 1, 5
- Don't extend to three times daily: This increases side effects without improving outcomes 4, 5, 3
Adult Dosing
For adults with otitis media (less common), use the pharmacokinetically enhanced formulation of 2000/125 mg twice daily. 7